Hi and welcome to “What Works Wednesdays” where we share a success story from one of our clinical cases. All names have been changed to preserve the privacy of the child and family. Our intent is to show readers how successful ABA can be.
Today’s success story is about a little guy named Nathan. At the time of intervention, Nathan was 6. Nathan had beautiful black hair, a heartwarming smile, and a contagious belly laugh. Nathan also had a pretty healthy belly–his nutritionist diagnosed him as obese. So, you ask, how could a picky eater be obese?
We cannot answer that question. However, we can tell you that Nathan was diagnosed with a genetic deletion syndrome as well as autism. Nathan demanded food at all hours of the day. If his parents did not feed him, he screamed, tantrummed, and hit himself in the head (also known as Self Injurious Behavior or SIB). When his parents offered him a non-preferred food, the tantrum and SIB worsened. As parents, they did not know what to do so they fed him preferred foods.
Nathan’s mother reported that Nathan would wake as early as 3 or 4 demanding food. He had never slept through the night. As you can imagine (or possibly even relate if you are a parent of a child with autism), this lifestyle caused a great deal of stress for Nathan and his family.
Given the presentation of demanding food at all hours of the day, combined with the fact that he was overweight and had low tone, we first suspected that “little” Nathan had Prader Willi Syndrome. However, his mother reported that he had been tested for this condition on more than one occasion and doctors had confirmed this was not the case.
Before Our Therapy Started
Nathan had been receiving feeding therapy for about 2.5 years from a speech therapist who specialized in feeding disorders. Nathan also had feeding objectives in his IEP. However, Nathan failed to make progress in eating a variety of foods. Thus, his mom contacted us. Prior to our services, we suggested that Nathan be seen by a nutritionist. As part of the services there, the nutritionist discovered that Nathan had a milk allergy. Nathan’s mom stopped all dairy products the weekend before we started therapy. Nathan was not happy about this change so you can imagine his distaste when he discovered that we had additional plans for him. Surprisingly though, Nathan immediately started sleeping through the night once dairy was removed! (Since Nathan started a dairy free diet, he has experienced a couple of dairy infractions. Each time this occurred, Nathan awakened during the night.)
We originally scheduled 5 days of therapy with three one-hour sessions each day (one for each meal). However, Nathan was sick on the first day so we postponed therapy leaving 4 days of scheduled therapy. (More therapy is always provided when necessary.) We started therapy by finding a highly preferred item that Nathan wanted to work for (interactive book on the iPad). This is also called a preference assessment. We allowed Nathan to play with the item and then we removed it and told him that when he tried his new food, he could have the item back.
At first, we only asked Nathan to touch the new food to his lip. This is called shaping. Nathan screamed, cried, and attempted to hit himself in the head. We simply blocked the behavior from happening by inserting our hand between his fist and his head. He also attempted to bang his elbows on the table. We blocked this behavior as well. Soon, Nathan decided that he should put the food to his lip and we praised him and gave him access to his iPad book. After a few trials, Nathan decided that the new food was not so scary and he ate it. Soon, Nathan was willing to try (and eat) all of the foods we presented to him. He continued to show his distaste for the new foods by screaming and crying. He also gagged a few times. However, it did not take long for him to realize that these new foods actually tasted good.
Generalization (Transferring the Behavior to New Situations)
Nathan’s challenging behaviors subsided and it was time to transfer therapy to Nathan’s parents. Nathan’s mom started therapy on the 3rd day of services. As we often see when the parents take over, Nathan attempted to scream, cry, and hit his head. His mom knew how to block the behaviors and she held strong. By the end of lunch on the 3rd day, Nathan ate willingly with his mother so Nathan’s dad joined Nathan and his mom for dinner. For the first time, Nathan and his family shared a meal with all family members eating the same foods!
On the last day of therapy, Nathan and his parents celebrated by going out to eat. The family enjoyed a healthy meal free from challenging behaviors. The following week, we accompanied Nathan to school to show his teachers how to support him during lunch and snacks. Sadly, Nathan’s classmate brought in pizza for lunch. Poor Nathan! He could no longer eat his favorite food. He cried briefly but his teacher showed him the wonderful new foods in his lunch box and ate his meal. Over time, Nathan began enjoying healthy foods. In fact, we recently posted a picture of a meal Nathan ate when we dropped by for a visit 7 months after feeding therapy. Nathan ate grilled chicken, Texas Caviar, raspberries, blackberries, and grilled vegetables with no challenging behaviors. In fact, he is now learning to eat slowly without stuffing and he is learning table manners such as wiping his mouth and putting his silverware down between bites.
Way to go Nathan! You worked hard to learn to eat such healthy foods! Giving up milk was not easy for you. Give your mom and dad a huge hug for their support through this difficult phase! It was not easy for them either.
We often see children in our clinic who have food sensitivities, allergies, and gastrointestinal issues. As such, we require the support and consultation of appropriately trained professionals prior to the commencement of feeding therapy. We see observable changes in behavior when milk or other allergens are removed from the diets of some (but not all) children. If you are interested in reading more about the Devil in the Milk, we found the book to be informative.